Embolic kidney infarction as a clinical manifestation of benign cardiac tumor

Introduction Cardiac myxoma (CM) is the most common type of benign primary cardiac tumors [1]. In 90% of cases, it localized in the left atrium (LA) and attached to the left side of the atrial septum by mobile pedunculus [2, 3]. The patients with CM exhibit various clinical manifestations, ranging from systemic infections and vasculitis to life-threatening cardiovascular disasters. In frequently the patients with CM are quite asymptomatic, pathognomonic signs and symptoms are absent [1-3]. The patients with CM can complain about shortness of breath, fever, weight loss and fainting. Commonly CM manifests with embolism in systemic circulation by tumor fragments or blood clots from its surface [1, 3, 4]. Sometimes CM can manifest with life-threatening arrhythmias, mitral valvular, left ventricular or abdominal aorta obstruction. Echocardiography (Echo) is the first line imaging modality. The prognosis is excellent when treated with prompt surgical resection [1, 3, 4]. The clinical case of LA myxoma in a young female without any history of cardiac disease is presented. The peculiarity of the case is the clinical manifestation in the form of renal colic due to embolic kidney infarction. Clinical case 37-years old female was hospitalized due to intensive right-sided lower back and groin pain. Previously she considered herself healthy and led active lifestyle. Within the past several months she has been noticing unexplained weakness and lightheadedness. She underwent the medical checkup just before hospitalization, an emotional disorder was diagnosed. At admission the typical symptoms of right-sided renal colic were present. Laboratory tests were within normal ranges, except Pcr 125 mcm/L and D-dimer 500 ng/mL. Urolithiasis was ruled out after ultrasound and multispiral computed tomography (MCT). Contrast enhanced MCT with image postprocessing was performed (Fig. 1A, B ): In the right kidney, a decrease in the contrast of the lower two-thirds of the parenchyma and several areas of wedge-shaped enhancement defects that involved both the cortex and medulla were found. A thin rim of cortex was continuing to enhance, due to collateral capsular perfusion. The main renal artery, segmental and lobar branches were contrasting without defects. At heart auscultation on patient’s left side the three-part rhythm and short protodiastolic murmur were registered at the apex. The auscultation in standing position was unremarkable. Echo demonstrated the slow-moving mass 5.0×5.2 cm with mixed echogenicity and smooth contour. The mass occupied almost the entire LA and it was attached to atrial septum (Fig. 1C ). A single small floating element no more than 3 mm, was visualized upon a smooth contour. The patient was transferred to special hospital with a diagnosis of a heart tumor for further treatment. During the surgery the mass of a heterogeneous consistency 5.0×5.5 cm, attached to the free wall of LA and part of atrial septum by pedunculus 0.7×2.0 cm was revealed. The tumor with pedunculus was excised and completely resected within healthy tissue (Fig. 2A, B ). Histopathological assessment confirmed the diagnosis of CM: stellate and process cells in the myxomatous substance with numerous foci of hemorrhage (Fig. 2C ). The postsurgical period proceeded without complications. The indicators of Pcr and D-dimer returned to normal ranges (95 mcm/L and 100 ng/mL resp.) Conclusion The presented case demonstrates the embolic kidney infarction as a clinical manifestation of left atrial myxoma in previously health young female without any hemostatic disorders. The substrate of the embolism was a thrombus fragment from the tumor surface. The absent of contrast defect in renal artery due to contrast enhanced MCT and transient increase D-dimer confirmed thromboembolic genesis of kidney infarction and supported the high probability of spontaneous thrombolysis. The clinical picture at admission was indistinguishable from typical renal colic. The case demonstrates the need for a prompt and focused search for the cardiac origin of embolic syndrome regardless of patient’s age, previous health condition and involved arterial vessel. Informed consent for publication of patient's information and images was obtained from our patient. The authors declare no conflict of interest.

инфаркт почки, миксома левого предсердия, эмболические осложнения, клинический случай, сardiac myxoma, embolism, kidney infarction, сlinical case

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